Provider Demographics
NPI:1265496335
Name:MARTIN, GARY ERICKSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ERICKSON
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-2478
Mailing Address - Country:US
Mailing Address - Phone:509-837-4022
Mailing Address - Fax:509-839-4022
Practice Address - Street 1:1723 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2478
Practice Address - Country:US
Practice Address - Phone:509-837-4022
Practice Address - Fax:509-839-4022
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000057311223G0001X
UT354974-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5045802Medicaid
WA91-1979056OtherTIN